Shoulder Dislocation:

Evidence Based Review

Context
Shoulder dislocations are common, accounting for approximately half of all joint dislocations
seen in the ED. Two peaks in incidence occur: one in males aged 2030 years (sport
injuries), and the other in females aged 6080 years (falls).
Anatomy/ pathophysiology
The shoulder is a ball and socket joint but in order to allow the range of movements required
(it is the most mobile joint in the body), it has only a small area of articular contact. Factors
that stabilise the gleno-humeral joint include deepening of the fossa by the glenoid labrum,
the joint capsule, the surrounding muscles and the negative intracapsular pressure (suction-
cup mechanism). Excessive forces can overcome these factors and result in dislocation.

Structures traversing the joint and neck of humerus, such as the brachial plexus, axillary
nerve and axillary artery, may be damaged during dislocation. The following have been
noted on arthroscopy:

Bankart lesions (tear of the anterior labrum +/- glenoid fracture) in up to 90% of patients
Hill-Sachs lesions (impact fracture of the humeral head) in up to 50% of patients
Partial or complete rotator cuff tears in approximately 10% of young patients and more than half of
elderly patients
Brachial plexus injuries in approximately 10% of patients
Axillary nerve injuries in approximately 10% of patients

Hill-Sachs and Bankart lesions are strongly associated with recurrent dislocations.




Hill-Sachs lesion


Figure 1. Hill-Sachs lesion
(reproduced with the permission of York Hospital Medical Illustration Department)




Bankart lesion

Figure 2. Bankart lesion
(reproduced with the permission of York Hospital Medical Illustration Department)

Clinical features and causes
The shoulder dislocates in one of four directions, with the consistent features being severe
pain and loss of function of the affected arm. The focus of the patient examination is
influenced by whether it is an isolated injury in a young sportsperson or as a result of a fall in
an elderly person. Inspection of the shoulder (from above, front, side and behind) should be
followed by comparison with the opposite side. Differences in contour, fullness of the
coracoid fossa and the position of the arm (abduction, adduction, internal or external
rotation) should be noted. Palpation of the entire upper limb should start proximally at the
sterno-clavicular joint and include attempted palpation of the glenoid fossa and acromion
process. Attempts at movement, either passive or active, are best avoided at this stage.
Instead the focus should be on the administration of adequate analgesia. The peripheral
circulation should be assessed by palpating the radial artery and a prompt focused
neurological examination performed. Sensation over the military badge area should be
specifically tested as altered or absent sensation suggests an axillary nerve injury.
Anterior dislocation (~96% of shoulder dislocations)
By far the most common type, the mechanism that causes an anterior shoulder dislocation is
usually forced abduction, extension and external rotation as a result of a fall onto the
outstretched arm. Occasionally, a significant posterior force striking the humeral head results
in an anterior dislocation. The humeral head usually comes to lie below and anterior to the
glenoid (subcoracoid). Clinically, this manifests itself by the patient holding the arm in
abduction and external rotation, with the elbow flexed and supported by the opposite hand.
The shoulder looks squared off, with fullness of the coracoid fossa and, in thin patients, the
acromion process is easily palpated.
Posterior dislocations (<4% shoulder dislocations)
These occur much less frequently than anterior dislocations but are commonly missed
because the clinical deformity and radiographic changes are subtle. It may occur from a
direct blow to the anterior shoulder, following a fall with the arm in internal rotation or when
the internal shoulder rotators contract and overcome the weaker external rotators during
seizures or electrocution. The arm is held adducted and in internal rotation. In comparison
with the opposite side, the anterior shoulder looks flattened with a prominent coracoid
process. Rarely, bilateral posterior dislocations occur following seizure or electrocution, and
in this case the clinical appearance of each shoulder will be similar. If shoulder movement is
assessed, external rotation is not possible.
Inferior dislocations (<1% shoulder dislocations)
The mechanism that causes this rare injury is a hyper-abduction force. The neck of the
humerus eventually pivots against the acromion, the inferior capsule tears and the humeral
head displaces inferiorly. The patient holds the arm fully abducted with the elbow flexed and
the patients forearm on their head (luxatio erecta). The rotator cuff is torn in 80% patients
and the axillary nerve injured in 60% of cases (Mallon et al, 1990).
Superior dislocations (extremely rare)
May be caused by significant traction forces applied to the abducted arm. Local structures
(e.g. the acromion and clavicle) are commonly damaged.
Diagnostic investigations
Radiographic imaging is advisable before reduction of a dislocated shoulder in all cases,
with the exception of habitual dislocators with lax joints in the absence of direct trauma
(Hendey, 2000). The BAEM (CEM, 2007) recommends that these radiographs are
performed within 60 minutes of arrival. If radiography is omitted, fractures may be missed or
may later be attributed to the reduction itself.

Fractures/ dislocations involving the humeral neck cannot be reduced using the common
techniques described in this module and may require open reduction under a general
anaesthetic. Conversely, co-existent fractures of the greater tuberosity of the humerus only
occasionally prevent successful closed reduction of the dislocation.

An anteroposterior shoulder radiograph will confirm most anterior dislocations and allow an
attempt at reduction. However, this view can appear normal with posterior dislocations.
Closer inspection of this normal radiograph may reveal that the greater tuberosity cannot
be clearly outlined due to internal rotation of the humeral head (which gives it a light bulb
appearance) and that the joint space may be altered.

Failure to gain a second view risks missing posterior dislocations, subtle glenoid fractures
and subluxations. The positioning of the patient for these views (e.g. scapular Y views) can
be painful and should preferably be performed by an experienced radiographer. Axillary
views, which require only 15 degrees of shoulder abduction, can be obtained in nearly all
cases. Musculoskeletal radiologists and local shoulder surgeons will dictate the views that
are taken in your hospital.






Figure 3. Axillary view. Note that the coracoid process always points forward
(reproduced with the permission of York Hospital Medical Illustration Department)


Differential diagnosis
The diagnosis is usually clear from the history. Occasionally the patient cannot give a clear
history (e.g. in cases of dementia, alcohol intoxication, or where the patient is post-ictal), or
examination does not allow specific localisation of pain (e.g. in an unco-operative or obese
patient). In these cases, the following conditions should be considered:

soft tissue injury of the shoulder
subluxation of the gleno-humeral joint
distal clavicle fracture
fractured neck of humerus
greater tuberosity avulsion
acromio-clavicular joint disruption
Management
The earliest record of shoulder reduction was found on an Egyptian tomb (3000BC), whilst
Hippocrates himself described the oldest method (400BC) still in use. It is difficult to think of
another condition in medicine that has so many different accepted methods of treatment.
The success rates are generally high for each technique and complication rates are low,
hence practitioners generally stick to the method with which they are most familiar with. No
high-quality trials have compared the various techniques.

The success of reduction depends upon the type of dislocation, whether it is a primary or
recurrent dislocation and, most importantly, how long it is since the joint dislocated.
Increasing muscle spasm with time results in a lower success rate. The BAEM (CEM, 2007)
recommends a target of attempting to reduce over 75% of dislocations within two hours of
presentation. Whichever technique is chosen, time needs to be taken to provide steady
application of the manoeuvre in order to encourage muscle relaxation. Sudden movements
cause pain and muscle spasm, which reduce the chance of success and increase the risk of
iatrogenic fracture.

Sedation and analgesia are not essential but should be considered in all cases. Analgesia
may involve one or more of Entonox, fentanyl, morphine or intra-articular lidocaine.
Sedatives used include midazolam and, under anaesthetic supervision, propofol (Dunn et al,
2006). The increased muscle tone that is associated with ketamine use makes it a poor
choice in this setting. Familiarity with each agent, the operators airway skills and local
guidelines will determine which analgesic/ sedation regime is used.
Reduction of an anterior dislocation
The Spaso technique (Miljesic and Kelly, 1998) involves vertical traction of the forearm with
the patient supine. Only when muscle spasm is overcome is the shoulder externally rotated.
This has a high success rate (87.5%) in inexperienced hands and is a single operator
technique.
The modified Milch technique (Milch, 1938; Beattie et al, 1986) involves abduction of the
arm whilst applying pressure to the humeral head with the other hand. Once full abduction
has been achieved, external rotation and traction are applied. It is successful in most cases
(up to 90%) and is relatively atraumatic.
Scapular manipulation (Anderson et al, 1982) involves rotating the inferior angle of the
scapula medially and the superior aspect laterally. It has an impressive success rate in
skilled hands (>90%) and is relatively atraumatic. However, the patient is prone, and if they
have been sedated this can potentially complicate airway management.
The chairback technique is quick and easy. The patient sits facing backwards astride a
chair with the affected arm hanging over the back of a normal or specially designed chair.
Once muscle relaxation is achieved, a little gentle downward traction at the wrist, sometimes
with external rotation, is applied. Theoretical complications from compression of axillary
nerves and vessels have not been widely reported and success rates of 72% (Noordeen et
al, 1992) and 77.8% (Black et al, 1998) without patient sedation have been reported.

Traction-countertraction (Apley and Solomon, 1993) involves the longitudinal traction in
the direction of the deformity and counter-traction by using a sheet wrapped around the
patient's chest.
Kochers method (Kocher, 1870), which involves traction and external rotation of the
humerus followed by adduction, risks causing spiral humeral fractures if muscle relaxation
has not been achieved first. Despite the recognised risks, 71% of orthopaedic and
emergency medical trainees at a recent international trauma meeting revealed that Kochers
was their preferred method (Leonard and Kiely, 2007).
The Hippocratic method (Hippocrates, 400BC), Eskimo technique (Poulson, 1988), Stimson
technique (Stimson, 1900), external rotation methods (Lendelmeyer, 1977), Snowbird
technique (Westin et al, 1995) and Cunningham method (Cunningham, 2003) are just a few
of the many other described methods for reducing anterior dislocations.

Reduction of a posterior dislocation
Abduction of the arm to 90 degrees is followed by constant axial traction and slow external
rotation (McLaughlin, 1952). There is a much lower success rate of reduction without general
anaesthetic. This may be partly accounted for by the delay before diagnosis as these
dislocations are commonly missed.

Reduction of an inferior dislocation
In-line traction of the abducted arm is followed by slow adduction (Mallon et al, 1990).
General anaesthesia may be required to effect reduction in a significant proportion of
patients.
Failure of reduction by the above methods (approximately 15% cases overall) should prompt
referral to the orthopaedic team for reduction under general anaesthetic.
Further assessment and follow up
Neurovascular deficit should be sought and documented both prior to and after reduction.
Two-view post-reduction radiographs should be performed to confirm relocation and the
absence of fractures caused by the reduction process itself. Early abduction and external
rotation movements predispose the shoulder to recurrent dislocations. To prevent this,
confirmed reduction should be followed by placement of the arm (flexed at the elbow) into a
sling designed to hold the arm against the body (or a simple sling worn under the patients
clothes). On discharge, the patient should be prescribed analgesia, have an orthopaedic
follow-up appointment made and be advised not to drive until authorised to do so by the
orthopaedic team. Following a primary dislocation in a young patient, the arm will be
mobilised after approximately three weeks (Kiviluoto et al, 1980) and the patient may return
to sport after an average of three months. Older patients may be mobilised sooner, with
physiotherapy input, to reduce the complication of stiffness.
Surgery may be offered to patients following recurrent dislocations, or to those who are
young and active after a first dislocation, since this group has an exceptionally high re-
dislocation rate. A Cochrane review (Handoll et al, 2004) found that traumatic primary
shoulder dislocations in young people (mean age of 22 years) were less likely to recur when
treated by surgery, as compared with conservative treatment (relative risk 0.20; 95% CI
0.11-0.33). Bankart and Hill-Sachs lesions are strongly associated with recurrent
dislocations.
There is limited evidence that splinting the arm in external rotation reduces the future risk of
dislocation (Itoi et al, 2007), but this is cumbersome. It is an option for patients whose
compliance can be guaranteed.
Pitfalls

delays to the first attempt at shoulder reduction lower the chances of a successful reduction in the ED
failure to recognise that the patients conscious level may drop once the painful stimulus is removed (i.e.
following shoulder reduction)
- if sedation has been used, increased vigilance is required during this period
failure to perform radiographs before attempted reduction, resulting in unidentified humeral neck
fractures or risking litigation for inflicted injuries that are subsequently identified
missing subluxations and posterior dislocations due to the failure to obtain a second radiographic view
failure to consider that shoulders may appear identical in bilateral posterior dislocation
failure to seek and document neurovascular deficit both prior to and after reduction
injuring axillary vessels and nerves by axillary compression during the manipulation
failing to inform and document that the patient should not drive until authorised to do so by the
orthopaedic team